Tibialis Anterior Tendonitis

N.B. Although recent research suggests that 'tibialis anterior tendinopathy' is the more appropriate term to describe overuse injuries to the tibialis anterior tendon, we will use the term 'tibialis anterior tendonitis' in this document as it is more widely known.

What is tibialis anterior tendonitis?

The tibialis anterior is a muscle which lies at the front of the shin and attaches to several bones in the foot via the tibialis anterior tendon (figure 1). The tibialis anterior is primarily responsible for moving the foot and ankle towards the head (dorsiflexion - figure 2), and, controlling the foot as it lowers to the ground during walking or running.

Figure 1 - Tibialis Anterior Muscle and Tendon

Figure 2 - Ankle Dorsiflexion

Whenever the tibialis anterior muscle contracts or is stretched, tension is placed through the tibialis anterior tendon. If this tension is excessive due to too much repetition or high force, damage to the tendon can occur. Tibialis anterior tendonitis is a condition whereby there is damage to the tibialis anterior tendon with subsequent inflammation and degeneration.

Signs and symptoms of tibialis anterior tendonitis

Patients with tibialis anterior tendonitis usually experience pain at the front of the shin, ankle or foot during activities which place large amounts of stress on the tibialis anterior tendon (or after these activities with rest, especially upon waking in the morning). These activities may include walking or running excessively (especially up or down hills or on hard or uneven surfaces), kicking an object with toes pointed (e.g. a football), wearing excessively tight shoes or kneeling. The pain associated with this condition tends to be of gradual onset which progressively worsens over weeks or months with continuation of aggravating activities. Patients with this condition may also experience pain on firmly touching the tibialis anterior tendon (figure 1).

Causes of tibialis anterior tendonitis

Tibialis anterior tendonitis typically occurs due to activities placing large amounts of stress through the tibialis anterior muscle. These activities may include fast walking or running (especially up or downhill or on hard or uneven surfaces) or sporting activity (such as running or kicking sports). Patients may also develop this condition following direct rubbing on the tibialis anterior tendon. This may occur due to excessive tightness of strapping or shoelaces over the tendon.

Diagnosis of tibialis anterior tendonitis

A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose tibialis anterior tendonitis. Further investigations such as an X-ray, Ultrasound or MRI scan may be required to assist with diagnosis and assess the severity of the condition.

Treatment for tibialis anterior tendonitis

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Contributing factors to the development of tibialis anterior tendonitis

There are several factors which can predispose patients to developing this condition. These need to be assessed and corrected with direction from a physiotherapist and may include:

muscle tightness (particularly of the tibialis anterior or calf)

muscle weakness (particularly of the tibialis anterior and tibialis posterior)

joint stiffness (particularly of the foot and ankle)

inappropriate or excessive training

poor foot biomechanics

inappropriate running technique

inappropriate footwear

inadequate warm up

inadequate rehabilitation following a previous ankle or lower limb injury

neural tightness

muscle imbalances

being overweight

Physiotherapy for tibialis anterior tendonitis

Physiotherapy treatment for patients with tibialis anterior tendonitis is vital to hasten the healing process, ensure an optimal outcome and reduce the likelihood of injury recurrence. Treatment may comprise:

Prognosis of tibialis anterior tendonitis

Most patients with this condition heal well with an appropriate physiotherapy program. This, however, can be a lengthy process and may take several months in patients who have had their condition for a long period of time. Minor cases of this condition that are identified and treated early can usually settle within a few weeks. Early physiotherapy treatment is vital to hasten recovery and ensure an optimal outcome.

Other Intervention for tibialis anterior tendonitis

Despite appropriate physiotherapy management, a small percentage of patients with this condition do not improve adequately. When this occurs the treating physiotherapist or doctor can advise on the best course of management. This may involve further investigation such as an X-ray, Ultrasound, CT scan or MRI, corticosteroid injection, autologous blood injection, pharmaceutical intervention or a review by a specialist who can advise on any procedures that may be appropriate to improve the condition. A review with a podiatrist for the prescription of orthotics and appropriate footwear advice may also be indicated.

Exercises for tibialis anterior tendonitis

The following exercises are commonly prescribed to patients with this condition. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 3 times daily and only provided they do not cause or increase symptoms.

Your physiotherapist can advise when it is appropriate to begin the initial exercises and eventually progress to the advanced and self massage exercises. As a general rule, addition of exercises or progression to more advanced exercises should take place provided there is no increase in symptoms.

Initial Exercises

Foot and Ankle Up and Down

Move your foot and ankle up and down as far as possible and comfortable without pain (figure 3). Repeat 10 - 20 times provided there is no increase in symptoms.

Figure 3 – Foot and Ankle Up and Down (left leg)

Foot and Ankle In and Out

Move your foot and ankle in and out as far as possible and comfortable without pain (figure 4). Repeat 10 -20 times provided there is no increase in symptoms.

Figure 4 – Foot and Ankle In and Out (right leg)

Lunge Stretch

With your hands against the wall, place your leg to be stretched in front of you as demonstrated (figure 5). Keep your heel down. Gently move your knee forward over your toes as far as possible and comfortable without pain. Hold for 5 seconds and repeat 10 times at a mild to moderate stretch provided there is no increase in symptoms.

Figure 5 – Lunge Stretch (right leg)

Advanced Exercises

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Tibialis anterior tendonitis is a condition characterised by damage to the tibialis anterior tendon with subsequent degeneration. Tibialis Anterior Tendonitis may occur due to activities such as excessive fast walking or running and typically causes pain at the front of the foot or ankle. Assessment and treatment by a physiotherapist is vital for an optimal outcome.